IHSTeCa MEMBERSHIP FORM For the Year:_______
*One calendar year (January to January)
District: 1  2  3  4  5
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LAST NAME__________________________
FIRST NAME_________________________		 HOME PHONE__________________
HOME FAX_____________________
HOME E-MAIL__________________
HOME ADDRESS_____________________________________________________

HOME CITY_______________________

HOME ZIP CODE______

Are you a Teacher?  Yes  No.  If No, what is your Occupation_________________________
Name of Business you are employed at or own____________________________________
Work Address______________________________ Work Phone____________________
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HIGH SCHOOL YOU ARE COACHING:____________________ SCHOOL PHONE: (     )__________
ADDRESS:_______________________________________SCHOOL FAX: (        )__________
ZIP CODE:______ SCHOOL E-MAIL___________________
If you are a school teacher: Do you teach at the High School that you coach at? Yes No
If No, what is the name of the school you teach at___________________________
School Address__________________________________School Phone (     )______________
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COACH OF BOYS: YES    NO
Head Coach__ Assistant Coach__

YEARS OF COACHING BOYS:___
RECORD COACHING BOYS:___

 COACH OF GIRLS: YES   NO
Head coach__ Assistant Coach__

YEARS OF COACHING GIRLS:__
RECORD COACHING GIRLS:___
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WINS: BOYS 100 WINS- YEAR:___
BOYS 200 WINS- YEAR:___
BOYS 300 WINS- YEAR:___		 GIRLS 100 WINS- YEAR:___
GIRLS 200 WINS- YEAR:___
GIRLS 300 WINS- YEAR:___
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COACH
OF YEAR		 BOYS DISTRICT- YEAR:___
BOYS STATE- YEAR:___		 GIRLS DISTRICT- YEAR:___
GIRLS STATE- YEAR:___
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NUMBER OF YEARS COACHING
BOYS:____YEARS.
FROM____TO____		 GIRLS:_____YEARS
FROM____TO____
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Please complete the above information and send along with your check for $25.00 made out to IHSTeCA to: Don Wafer, IHSTeCA Secretary-Treasurer, 3208 E. Randal Drive, Muncie, IN 47303.